1083647069 NPI number — LTC HEALTHCARE OF CONVERSE, INC.

Table of content: (NPI 1083647069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083647069 NPI number — LTC HEALTHCARE OF CONVERSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LTC HEALTHCARE OF CONVERSE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083647069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
925 N POINT PKWY
Provider Second Line Business Mailing Address:
SUITE 440
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30005-5210
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-619-0866
Provider Business Mailing Address Fax Number:
770-870-2892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 MESQUITE PASS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONVERSE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78109-2461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-650-0551
Provider Business Practice Location Address Fax Number:
210-650-4472
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANSTIS
Authorized Official First Name:
LOUANN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRIVACY OFFICER
Authorized Official Telephone Number:
770-619-0866

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  115216 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com